It has been 100 years since Legg, Calve, Perthes, and Waldenstrom originally described osteonecrosis of the skeletally immature capital femoral epiphysis. This disorder, now referred to as Legg-Calve-Perthes disease (LCPD), can cause permanent deformity of the hip, including both the femoral head and acetabulum. Children, adolescents, and young adults with a deformed hip tend to function well over the short term. However, many will develop an extruded femoral head with a progressive deformity that leads to degenerative osteoarthritis in later life. The disorder has been surrounded by controversy over the years, and its management is still widely debated. Treatment of children with LCPD is dependent on several factors including the age at clinical onset, extent of capital femoral epiphyseal involvement, stage of the disorder, and deformity of the femoral head and acetabulum at diagnosis. The use of abduction orthoses has been a controversial method of treatment. This section is a review of the present use of bracing in this disorder.
HISTORY OF ORTHOTIC USE
The treatment of tuberculosis prompted the earliest methods of hip containment. Bed rest, traction, and use of weight-limiting braces have previously been described.1–14 Containment for treatment of LCPD was first described in 1928 by AO Parker as reported by Meehan et al.2 In theory, containment places the involved portion of the capital femoral epiphysis within the acetabulum, with the goal of promoting a round femoral head. Salter3 conducted biological studies on immature ambulatory pigs demonstrating “biologic plasticity” in the capital femoral epiphysis in the postinfarction period. He also showed that a normal spherical contour could be preserved with carefully maintained acetabular containment of the regenerating epiphysis, while uncontained heads continued to degenerate and become deformed.
Early containment treatment often included limited weight bearing. Mose15 compared 3 methods of conservative treatment and in 1964 proposed that children had better outcomes with recumbent bracing than with ambulatory bracing. In addition, his review of the literature showed that combining recumbency with daily range of motion exercises improved the shape of the femoral head and flexibility of the hips. Katz4 subsequently showed that recumbency should be combined with abduction for better containment and remodeling of the femoral head.
Following Salter's logic, Petrie and Bitenc5 believed that the more deformed lateral and anterior portions of the femoral head could be molded by placing the capital femoral epiphysis in the acetabulum. They felt that a long period of recumbency was difficult on patients and their families and felt that patients should be ambulatory as long as the head was well contained in the acetabulum. They sought to achieve a better treatment that allowed the patient to be active, but still maintain the lower extremities in an abducted and internally rotated position. In 1971, they published successful results using an abducted weight-bearing plaster cast (Fig. 1). On average, children remained in these casts for 19 months with 60% good results, 31% fair, and 9% poor. Salter16 applied the Mose15 criteria (concentric circles spaced 2 mm apart) to examine different methods of containment and in 1979 published results showing that nonoperative management (braces or bed rest) of children diagnosed at 6 years of age or older had only 37% good and 66% satisfactory results (good and fair), whereas 34% had poor results. Conversely, his innominate osteotomy group had 77% good results and 94% satisfactory (good and fair), whereas only 6% had poor results. This suggested less efficacy with the brace despite the fact that the osteotomy group was older and had more progressive disease at the time of diagnosis.
Furthermore, in 1971, the Scottish Rite Hospital in Atlanta introduced their ambulatory abduction orthosis designed to contain the femoral head in the acetabulum, prevent further deformity, and allow remodeling without limiting activities (Fig. 2).2 Several other orthoses were developed about the same time including the Toronto, Newington, Tachdjian and Jovett, Harrison and Turner, Houston A-frame, Roberts, and Katz braces.6–8 The majority of the braces, such as the Scottish Rite orthosis, increase anterior and lateral coverage. This differed from Petrie casts, which increased lateral and anterior coverage while sacrificing some posterior containment.17 Over the next few decades, children were treated with both casts and braces at many centers throughout the world.
Despite all of this, 2 significant studies of brace treatment were unable to show that containment in braces has provided any benefit over observation and range of motion exercises.2,9 In 1992, Martinez et al9 reviewed 31 patients with Catterall III and IV hips treated with the Atlanta Scottish Rite orthosis. They used the criteria of Mose,15 determining the deviation from concentric circles on a radiograph. None of the hips had a good result at a mean follow-up of 7 years. Twelve hips (35%) had a fair result and 22 hips (65%) were classified as poor. They concluded that severely involved hips should not be treated with a weight-bearing abduction brace. In the same year, Meehan et al2 evaluated 34 patients who were all older than age 6 at the time of diagnosis and had Catterall III or IV hips. Long-term follow-up of the children showed poor results with use of the Scottish Rite orthosis. On the basis of the Mose criteria, 3 patients (8%) had a good result, 9 (27%) had a fair result, and 22 (65%) had a poor result. Although these were not comparative studies, both authors felt that the weight-bearing abduction orthosis offered no advantage compared with other methods of management or with no treatment in more deformed hips.
THE PRACTICE OF BRACING
The ideal brace provides abduction of each extremity great enough to prevent swinging and hip adduction on the involved side. The older braces and Petrie casts were made with a bar placed between them to help maintain abduction, whereas the Scottish Rite orthosis can now be made with hip hinges that are strong enough to maintain wide abduction in each hip. A telescoping bar can provide more strength and still allow reciprocal motion. Braces such as this usually end above the knee, allowing knee flexion and extension. As they are not as limited in flexion and extension, these braces also allow ambulation. Bracing is sometimes preceded by an adductor tenotomy if the child does not attain adequate abduction with therapy. They are followed with anteroposterior and frog pelvis radiographs out of the orthosis every 3 to 4 months. Discontinuation or weaning of the brace remains controversial. Skaggs and Tolo13 in 1996 stated that there was no clear evidence showing when containment ceases to be beneficial. Their patients were generally weaned when the lateral epiphysis showed some evidence of reossification on a radiograph. Herring18 also felt that use of the brace could be discontinued when there is early reossification of lateral aspect of the femoral head, but he added that a brace is rarely worn for more than 12 months. Thompson and Weston19 demonstrated that bracing could be discontinued when there is subchondral reossification of the epiphysis.
The family plays a pivotal role in successful treatment with an orthoses. They must agree to the use of the brace, must be able to understand that it needs to be worn consistently to be effective, and must know how to properly apply the brace.1 As with any brace, compliance is also an issue and can be difficult to track. Price et al20 in 1988 showed that braces were better tolerated than casts, and both had significant behavioral and self-esteem issues associated with their use.
INDICATIONS FOR BRACING
Maintenance of hip motion during containment of the involved femoral head is the most common basis of treatment of LCPD. Goals of treatment are maintenance of femoral head containment, hip mobility, and relief of pain. Once the patient has been assessed and the femoral head involvement indicates the need for active treatment, abduction and internal rotation should be restored as much as possible. In addition, the physician must be certain that the hips can be contained congruently and that a flattened femoral head is not creating a hinge effect. Only then can treatment progress to containment. The long-term goal of containment is to obtain a spherical femoral head.1
Children can be divided into treatment groups based on extent of involvement of the femoral head and age at clinical onset. Children with less femoral head involvement including those with Catterall group I or II, Salter-Thompson group A, or lateral pillar group A involvement and those who are ≤5 years of age at clinical onset can be observed. Most will have mild symptoms and excellent results even without treatment. Children with more involvement of the femoral head include those in Catterall group III or IV, Salter-Thompson group B, and lateral pillar group B, B/C border or C involvement, and who are 6 years of age or older are main candidates for containment treatment. There is a consensus in the literature that older children in these groups will progress to an increasing degree of disability if left untreated.1,11,20–22
Age plays an important role in the decision of how to treat these patients. Cooperman and Stulberg10 showed that patients under the age of 8 years at disease onset with minimal subluxation treated with crutch walking or ambulatory containment had no difference in outcome. Skaggs and Tolo13 suggested that containment is indicated for children 6 years of age and older if there are ≥2 poor prognostic indicators including persistent or recurrent synovitis, lateral subluxation, involvement of the lateral pillar, or involvement of nearly 50% of the capital femoral epiphysis. They reported using bracing for children ≤6 years of age and surgical containment for children 7 years of age and older. Wiig et al11 recently published the results of their experience in Norway. Patients who were ≤6 years of age with >50% head involvement, who were treated with physiotherapy, Scottish Rite orthosis, or femoral varus osteotomy produced 53%, 46%, and 52% hips in the Stulberg I/II classification group, respectively, at 5 years of follow-up. Herring22 published the results of a prospective multicenter study of the effect of treatment on outcome. They evaluated 337 patients (age 6 to 12 y at time of onset) with 345 affected hips divided into 5 treatment groups consisting of no treatment, range-of-motion exercises, brace treatment, femoral osteotomy, and innominate osteotomy and found “no differences in outcome among the hips with no treatment, those treated with bracing, and those treated with range-of-motion therapy.” They also noted that those children over the age of 8 years in the lateral pillar B and B/C border groups had significantly better outcomes with surgery than with nonoperative treatment. However, children ≤8 years old with lateral pillar B hips had equal outcomes with nonoperative and operative treatment. Group C hips in children of all ages had unfavorable outcomes. Hefti and Clarke14 performed a study evaluating the practices of members of the European Pediatric Orthopaedic Society. A survey was conducted to gather the opinions of 150 orthopaedists. No more than 5.3% of the orthopaedists chose nonoperative containment for any case. They stated that use of an abduction splint or Petrie cast was suggested in only very few centers.
Petrie casts can be useful in hips with deformed femoral heads but before complete reossification. Hips that are subluxated or have hinged abduction are ideal candidates. These hips will benefit by an adductor tenotomy and iliopsoas recession. This will allow the deformed femoral head to be reduced into the acetabulum. Both hips are then placed in wide abduction and the Petrie cast applied. Maintaining the femoral heads in abduction and then allowing flexion and extension of the hip allows rapid remodeling of the femoral head. Within 2 to 4 months the hips will have sufficient remodeling to then undergo surgical containment. This technique is frequently called the “salvage” technique or procedure.
In summary, although the theory behind the use of the weight-bearing abduction orthosis seems sound, the literature does not demonstrate that it is significantly better than other nonoperative methods of containment. Use of bracing for LCPD has fallen out of favor in recent years, and this is supported by a growing body of evidence that braced children do not gain any improvement in the anatomic structure of the femoral head or ultimate range of motion. Our recommendation is that the abduction orthosis should be used rarely in the treatment of LCPD.
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